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Prescribing Optimization Method for Improving Prescribing in Elderly Patients Receiving Polypharmacy

Results of Application to Case Histories by General Practitioners

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Abstract

Background

Optimizing polypharmacy is often difficult, and critical appraisal of medication use often leads to one or more changes. We developed the Prescribing Optimization Method (POM) to assist physicians, especially general practitioners (GPs), in their attempts to optimize polypharmacy in elderly patients. The POM is based on six questions: (i) is undertreatment present and addition of medication indicated; (ii) does the patient adhere to his/her medication schedule; (iii) which drug(s) can be withdrawn or which drugs(s) is/are inappropriate for the patient; (iv) which adverse effects are present; (v) which clinically relevant interactions are to be expected; and (vi) should the dose, dose frequency and/or form of the drug be adjusted?

Objective

The aim of this study was to evaluate the usefulness of the POM as a tool for improving appropriate prescribing of complex polypharmacy in the elderly.

Methods

Forty-five GPs were asked to optimize the medication of two case histories, randomly chosen from ten histories of geriatric patients admitted to a hospital geriatric outpatient clinic with a mean ± SD of 7.9±1.2 problems treated with 8.7±3.1 drugs. The first case was optimized without knowledge of the POM. After a 2-hour lecture on the POM, the GPs used the POM to optimize the medication of the second case history. The GPs were allowed 20 minutes for case optimization. Medication recommendations were compared with those made by an expert panel of four geriatricians specialized in clinical pharmacology. Data were analysed using a linear mixed effects model.

Results

Optimization was significantly better when GPs used the POM. The proportion of correct decisions increased from 34.7% without the POM to 48.1% with the POM (p=0.0037), and the number of potentially harmful decisions decreased from a mean ±SD of 3.3±1.8 without the POM to 2.4±1.4 with the POM (p=0.0046).

Conclusion

The POM improves appropriate prescribing of complex polypharmacy in case histories.

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References

  1. Stich ting Farmaceutische Kengetallen. Polyfarmacie. Pharm Weekblad 2005; 32: 968

    Google Scholar 

  2. Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2004; 57(1): 6–14

    Article  PubMed  CAS  Google Scholar 

  3. Frazier SC. Health outcomes and polypharmacy in elderly individuals: an integrated literature review. J Gerontol Nurs 2005; 31: 4–11

    PubMed  Google Scholar 

  4. Leendertse AJ, van den Bemt PMLA, Egberts ACG. Hospital admissions related to medication (HARM). Arch Int Med 2008; 168: 1890–6

    Article  Google Scholar 

  5. Bjorkman IK, Fastborn J, Schmidt IK, et al., the Pharmaceutical Care of the Elderly in Europe Research (PEER) Group. The Pharmaceutical Care of the Elderly in Europe Research (PEER) Group: drug-drug interactions in the elderly. Ann Pharmacother 2002; 36: 1675–81

    Article  PubMed  CAS  Google Scholar 

  6. Shi S, Mörike K, Klotz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol 2008; 64(2): 183–99

    Article  PubMed  Google Scholar 

  7. Kuijpers MAJ, van Marum RJ, Egberts ACG, et al., the OLDY (OLd people Drugs and dYsregulations) Study Group. Relationship between polypharmacy and under-prescribing. Br J Clin Pharmacol 2008 Jan; 65(1): 130–3

    Article  PubMed  Google Scholar 

  8. Sloane PD, Gruber-Baldini AL, Zimmerman S, et al. Medication undertreatment in assisted living settings. Arch Intern Med 2004; 164(18): 1957–9

    Article  Google Scholar 

  9. Spinewine A, Schmader KE, Barber N, et al. Prescribing in elderly people: 1. Appropriate prescribing in elderly people: how well can it be measured and optimized? Lancet 2007; 370: 173–84

    Article  PubMed  Google Scholar 

  10. Claxton AJ, Cramer J, Pierce C. A systematic review of the association between dose regimens and medication adherence. Clin Ther 2001; 23: 1296–310

    Article  PubMed  CAS  Google Scholar 

  11. Kripalani S, Yao X, Haynes B. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med 2007; 167: 540–50

    Article  PubMed  Google Scholar 

  12. Kuzuya M, Endo H, Umegaki H, et al. Factors influencing nonadherence with medication regimens in the elderly. Nippon Ronen Igakkai Zasshi 2000; 37: 363–70

    Article  PubMed  CAS  Google Scholar 

  13. Ryan AA. Medication adherence and older people: a review of the literature. Int J Nurs Stud 1999; 36: 153–62

    Article  PubMed  CAS  Google Scholar 

  14. Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006; 54: 1516–23

    Article  PubMed  Google Scholar 

  15. Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: 1825–32

    Article  PubMed  CAS  Google Scholar 

  16. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997; 157: 1531–6

    Article  PubMed  CAS  Google Scholar 

  17. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003; 163: 2716–24

    Article  PubMed  Google Scholar 

  18. Wessel AM, Nietert PJ, Jenkins RG, et al. Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. Am J Geriatr Pharmacother 2008; 6: 21–7

    Article  Google Scholar 

  19. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45(10): 1045–51

    Article  PubMed  CAS  Google Scholar 

  20. Barry PJ, Gallagher P, Ryan C, et al. START (Screening Tool to Alert doctors to the Right Treatment): an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007; 36: 632–8

    Article  PubMed  CAS  Google Scholar 

  21. Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to the Right Treatment): consensus validation. Int J Clin Pharmacol Ther 2008; 46(2): 72–83

    PubMed  CAS  Google Scholar 

  22. Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med 2004; 140(9): 714–20

    PubMed  Google Scholar 

  23. Holland R, Desborough J, Goodyer L, et al. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol 2007; 65(3): 303–16

    Article  PubMed  Google Scholar 

  24. Schmader KE, Hanlon JT, Pieper CF, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med 2004; 116(6): 394–401

    Article  PubMed  Google Scholar 

  25. Spinewine A, Swine C, Dhillon S, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized controlled trial. J Am Geriatr Soc 2007; 55(5): 658–65

    Article  PubMed  Google Scholar 

  26. Nederlands Huisartsen Genootschap. NHG-standaarden [online]. Available from URL: http://nhg.artsennet.nl [Accessed 2009 Jun 24]

  27. Farmacotherapeutisch Kompas. College voor Zorgverzekeringen [online]. Available from URL: http://www.fk.cvz.nl [Accessed 2009 Jun 24]

  28. Wetenschappelijk Instituut Nederlandse Apothekers. Koninklijke Maatschappij ter bevordering van de Pharmacie Webrapportages farmacotherapie [online]. Available from URL: http://www.winap.nl [Accessed 2009 Jun 24]

  29. Centraal BegeleidingsOrgaan voor de intercollegiale toetsing. Kwaliteitsinstituut voor de gezondheidszorg. Richtlijnen [online]. Available from URL: http://www.cbo.nl [Accessed 2009 Jun 24]

  30. Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Ther 1999; 21: 1074–90

    Article  PubMed  CAS  Google Scholar 

  31. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006; 166: 605–9

    Article  PubMed  Google Scholar 

  32. Mannesse CK, Derkx FH, de Ridder MA, et al. Do older hospital patients recognize adverse drug reactions? Age Ageing 2000; 29(1): 79–81

    Article  PubMed  CAS  Google Scholar 

  33. Naranjo CAA. Method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30(2): 239–45

    Article  PubMed  CAS  Google Scholar 

  34. Johnell K, Klarin I. The relationship between number of drugs and potential drug-drug interactions in the elderly. Drug Safety 2007; 30(10): 911–8

    Article  PubMed  Google Scholar 

  35. Indiana University Department of Medicine. Division of Clinical Pharmacology. Cytochrome P450 drug interaction table [online]. Available from URL: http://medicine.iupui.edu/flockhart/ [Accessed 2009 Jun 24]

  36. Rimon E, Kagansky N. Can creatinine clearance be accurately predicted by formulae in octogenarian in-patients? Q J Med 2004; 97: 281–7

    Article  CAS  Google Scholar 

  37. Fadem SZ. Cockroft Gault calculator [online]. Available from URL: http://nephron.com/cgi-bin/CGSI.cgi [Accessed 2009 Jun 24]

  38. Stevens LA, Coresh J, Greene T, et al. Assessing kidney function: measured and estimated glomerular filtration rate. N Engl J Med 2006; 354: 2473–83

    Article  PubMed  CAS  Google Scholar 

  39. Hanlon JT, Aspinall SL, Semla TP, et al. Consensus guidelines for oral dosing of primarily renally cleared medications in older adults. J Am Geriatr Soc 2009; 57(2): 335–40

    Article  PubMed  Google Scholar 

  40. Koninklijke Nederlandse Maatschappij ter bevordering van de Pharmacie. Kennisbank. G-standaard verminderde nierfunctie. Tabel bij ‘Verminderde nierfunctie. Doseringsadviezen voor geneesmiddelen’ [online]. Available from URL: http://kennisbank.knmp.nl [Accessed 2009 Jun 24]

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Acknowledgements

No sources of funding were used to assist in the conduct or preparation of this study. The authors have no conflicts of interest that are directly relevant to the content of this study. The authors would like to thank E.P. Martens, PhD, for his help with regard to the statistical analysis.

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Authors and Affiliations

  1. Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands

    A. Clara Drenth-van Maanen, Rob J. van Marum, Wilma Knol &  Paul A. F. Jansen

  2. Department of Geriatric Medicine, Catharina Hospital, Eindhoven, the Netherlands

    Carolien M. J. van der Linden

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  1. A. Clara Drenth-van Maanen
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  2. Rob J. van Marum
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  3. Wilma Knol
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  4. Carolien M. J. van der Linden
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  5. Paul A. F. Jansen
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Correspondence to Paul A. F. Jansen.

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Drenth-van Maanen, A.C., van Marum, R.J., Knol, W. et al. Prescribing Optimization Method for Improving Prescribing in Elderly Patients Receiving Polypharmacy. Drugs Aging 26, 687–701 (2009). https://doi.org/10.2165/11316400-000000000-00000

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